Using real patients in e-learning: case-based online training in child and adolescent psychiatry

Objectives: In undergraduate medical education and in the subject of child and adolescent psychiatry, examining young patients face-to-face is a key element of teaching. With the abrupt shutdown of face-to-face teaching caused by the SARS-CoV-2 pandemic, a case-based online training program integrating audio and video of real patients was developed. Methods: The blended learning platform CaseTrain guides medical students in their final year through real child-psychiatric patient cases, such as anorexia, autism, or attention deficit disorder, through presentation of video and audio of real patients and parents. The teaching format complements lectures on child psychiatric topics, comprising asynchronous elements (self-study using the digital material) as well as synchronous elements (web-conferences with a specialist). Learning objectives for students were set to develop knowledge of the spectra of psychiatric disorders that affect children and to recognize approaches how to assess and manage common psychiatric problems of childhood and adolescence. Results: The feedback from medical students through oral and written evaluation was positive. They appreciated getting to know ‘real-world patients’ in times of such a pandemic, to learn explorative techniques from role models, and to be in close contact with the supervising specialist. In consequence of critical feedback on the length of some video sequences, these training units will undergo revision. Conclusions: Case-based online training may continue to be a useful option in a post-pandemic future as integral part of medical education, complementing face-to-face lectures and training in (child) psychiatry.


Objectives
Real-patient cases are known to be effective in developing students' self-directed learning skills, improving their confidence in future patient encounters, and fostering knowledge gains [1]. In undergraduate education and in the subject of child and adolescent psychiatry in particular, assessing the history of young patients face-to-face, observing their mood, social interaction, and behavioral characteristics are key elements of teaching. Thus, lectures and seminars usually include live interaction between the examiner and patients providing authenticity and enhanced instructiveness considered as crucial advantages by students [2]. With the abrupt shutdown of face-to-face teaching in the course of the SARS-CoV-2 pandemic, we developed a case-based online training program, integrating audio and video of real patients aiming to transfer the real-life experience into an online format. The case-based learning approach was chosen and transferred online to ensure the exposition of students to real-world patient scenarios despite the given absence in clinic [3]. The aim of the online training was to enhance students' existing theoretical knowledge and to develop their clinical reasoning skills in common psychiatric disorders that affect children [4].

Method: case-based online training
Within CaseTrain, a blended learning platform established at the University of Würzburg [5], [6], [7], medical students are presented with real child-psychiatric patient cases presenting different mental diseases (see table 1). We produced video and audio sequences while interviewing patients and parents/carers -complemented in a few cases with simulated patients from the medical team. These sequences included interviews on the medical history (see figure 1) and explorations into psychopathological aspects, each with a duration of 10 to 40 minutes. Other videos presented characteristic behavioral features and treatment methods during a therapy lesson, e.g. with an autistic child (see figure 2). All EU data protection laws (GDPR) were applied. The online training replaced a compulsory course for students in their fifth year of the six-year degree course in human medicine. The training concept comprised an asynchronous and a synchronous element.  During the web conferences, the underlying educational model was to compile the students' hypothesis generation, pattern recognition, context formulation, diagnostic method interpretation, differential diagnosis, and diagnostic verification approaches as key elements of clinical problem solving [8]. The detailed learning objectives of the online training (parts A and B) are listed in table 1.
Students were asked for feedback at the end of each web conference. Additionally, they rated their satisfaction with the online training by means of an online evaluative survey (5-point Likert scale: 1=strongly agree, 5=strongly disagree).

Results
We experienced a great commitment of patients and families as well as the staff in their respective contributions to the design of the CaseTrain units. Student feedback has been highly positive, pointing out the experience of real patients in times of the pandemic, the deeper insight into child psychiatry, the explorative techniques from role models, and the close contact with the teaching consultant. Based on the verbal feedback on the length of some video sequences, training units are being revised where appropriate. A total of 23 students (21.3% of the total semester) participated in the survey. They rated the item "The materials and media were suitable to achieve the goals set" with a mean value of 1.4±0.6 and the item "On the basis of my previous knowledge, I have learned a lot" as 1.4±0.8. The highest item rating of 1.1±0.5 was achieved for "I had the opportunity to exchange with the teaching staff and ask questions". This online training program was ranked second place in the faculty ranking of all the clinical courses taught within the degree program. The supervising specialists experienced the success of online meetings to be dependent on the active participation of students. Hence, reducing group sizes and includ-ing role play may prove beneficial. Technical problems were scarce, since the contact details for technical support were available in advance.

Conclusions
During the SARS-CoV-2 pandemic, students were grateful for the opportunity to study with real cases that the program provides, as they reflect polymorphisms of actual clinical material encountered in everyday practice [8].
The online training program presented here may remain as a useful tool in a post-pandemic future, complementing face-to-face lectures and practical training sessions. Online cases may enhance a patients' willingness to participate in teaching, as their presentation can be avoided in large lectures. Furthermore, different phases of the clinical picture and therapeutic progress may be presented, thus promoting knowledge gain. We are continuing with the implementation of case-based online training, expanding with additional disorders, and extending the application to courses in preclinical medical school. Further research may also be needed to address the question as to what extent perceived student prejudice with respect to psychiatric illnesses in children and adolescents may be reduced through online courses to a degree replacing the face-to-face contact.

Competing interests
The authors declare that they have no competing interests.